Meniscal Tear? Everything you need know! (symptoms surgery and recovery)

okay we're here for another podcast um today we're with uh mr simon moyes who i've worked with for many years um and we're here to talk about municipal tears which is one of the most common conditions we see but also one of the most common conditions where we work together to try and get patients better so should we just start with an introduction simon you want to give us an idea of that i'm simon moyes i'm a consultant orthopedic surgeon here at the cromwell uh i'm a founder of capital orthopedics which is a group of like-minded orthopedic surgeons and sports medicine physicians and i've been working with chris and complete for many years now yes certainly quite a few years so we're going to get into the nitty-gritty of meniscal tears but we're going to start with some of the sort of more basic questions that patients often have or what may be relevant to their condition so what is the meniscus first of all so each knee has two menisci or meniscuses and inside one and an outside one i'll show you here on the model and the meniscus is a shaped like a new moon and it's a rubbery it's a rubbery shock absorber you have a big one on the inside and a more mobile smaller one on the outside of the knee and they are rubbery rubbery shock absorbers uh they're stabilizers for the knee or secondary stabilizers for the knee and they also have a role in helping to maneuver the lubricating fluid sun over your fluid around inside the joint perfect and so we've got one on the inside which is the medial meniscus and the one on the outside is the lateral the medial is the bigger one the lateral one which we're definitely going to come on to is smaller but more mobile and can particularly be a problem um so that's the role of it so how do you enjoy who gets it who injures this meniscus how does it happen there's really two main uh groups of people that injure their meniscus so there's the younger fit active person that has a big acute injury maybe skiing or part of a football injury or part of a fall down the stairs you know a big acute injury they remember a specific event when they something happened inside their knee there was acute pain often a popping sensation or a tearing sensation in their knee the knee becomes very painful and difficult to walk on afterwards the knee swells up typically within a few hours they're limping around it doesn't settle and they continue to have quite focal pain over where where the meniscus is torn i have a sensation of weakness in the knee it feels difficult typically going downstairs dealing with stairs turning corners that's that's one group and the other group is much more my generation uh whereby my generation so it's called more age-related wear and tear changes and as as we get older our meniscus gets generally a bit more fragile and soggy and it gets fatty infiltration into it becomes far less rubbery so it loses its shock absorption and cushioning and the free edge of it which should be shaped like the edge of a new moon becomes frayed like a the bottom of an old pair of jeans and it starts to rip and shred and that can happen and they slowly develop similar but much less severe symptoms so they get more niggles than symptoms building up typically over a few weeks or months and they come in to you or me or their gp or anyone saying you know i've got i've got this pain and it's sore and it they have fewer mechanical symptoms really more just generalized aching swelling some stiffness they do get some clicking from time to time it's not a big issue and they do but they don't record a specific event so those are the two main groups of patients yeah so we've got that where somebody's had and generally in the younger patient you've had that sudden incident where you've got a tearing incidency that acute tear and then you've got that degenerative or wear and tear type presentation in the older client and obviously i assume there's some overlap in there as well so should we deal with them because they are actually if we think about it they are they're dealt with quite differently aren't they absolutely so i think we should talk about let's talk about the first one so that's the younger sort of meniscal tear so where you've had that acute incident so do you want to give us a bit more of an idea you've already said about twisting injuries and that sort of thing and how they present um so what happens actually when you get a tear is it on the inside outside and what do you do about it so the anatomy or three-dimensional architecture of the meniscus is actually quite complicated and i don't want to baffle the audience with too much science but enough to say that the meniscus is divided into uh a front middle and back zone yeah and an inner middle and outer zone yep and as you those different zones can have different types of tears and those tears can run in different planes so without getting too complicated tears in certain zones of the meniscus are much more amenable to repair rather than uh non-operative treatment if yeah if for want of a better way of going about it without complicating it too so basically you've got that that moon shape and depending on where the tear is depends on potentially how you how you manage it yeah does that also link because a lot of patients will say well i've been told i've got a meniscal tear so an acute tear is it going to get better is it going to heal itself does that relate into the zones as well yes absolutely so the take home message is that you do not want to lose the shock absorpting a shock absorbing capacity of your meniscus because if you do particularly if you're young you know by young i mean 20s 30s even early 40s if you lose the shock absorption of your meniscus then you've got about a 60 chance of the knee becoming arthritic in a 10-year period so we have to as clinicians do everything we can to preserve the municipal function as best we can so when you see someone who presents particularly young with an acute meniscal tear you need to work out the best ways to preserve that meniscus and so you have to think to yourself is this torn meniscus going to heal on its own yeah or is this true meniscus going to require arthroscopic surgery to repair it yeah so there's quite a lot to consider isn't there certainly when i start i mean i've i've had a meniscectomy and one of our physios had a meniscectomy and i've seen lots of people have had meniscectomies in their sort of well one guy was in their teens 20s 30s and they all they're all developing including myself on the inside of my knee arthritis so 20 10 years ago the idea was just if you like resect tidy up the meniscus have a meniscectomy and then see how you get on but now we've got that knowledge that you are quite likely you said 60 particularly in those active people to then develop arthritis as a result of that so we need to try and preserve it if we can the other thing about or the importance of repairing the meniscus or preserving the municipal function is that not only do you protect against osteoarthritis later you're more likely to get back to the level of activity that you were enjoying before if you can preserve it right and uh you're going to have less less pain a better function if you can preserve it so it's you know preservation is the name of the game already here absolutely so let's how would an acute meniscal tear present in your clinic um an isolated meniscal tear this is without an associated ligament injury would be a football injury a fall they might do it boxing in the gym doing some training or you know it can be just just an awkward twisting injury stepping off a step yeah so they'll present a sudden a sudden pain often a tearing sensation something that will cause cause them to often you know scream out in pain they know they've had an acute injury they'll have difficulty weight-bearing afterwards they'll notice that the knee is swollen after a few hours it they hope that it will settle it usually doesn't or partially does and then two weeks later they're still in trouble yeah yeah the more extreme versions is when the meniscus tears so much that part or all of the meniscus can displace inside the knee and you can end up with what's called a locked knee and this means that the knee won't fully straighten and won't fully bend and that's because the meniscus becomes basically jammed inside the knee and it goes from its normal position and it sort of bucket handles over into the middle of the knee so it you just can't straighten the knee there you cannot straighten the knee yeah and you can't bend the knee all the way yeah yeah and then that becomes a surgical emergency yeah and uh you have to obviously get them into clinic scan them and then arthroscopically relocate the uh dislocated meniscus and ideally repair it yeah sometimes it's not repairable and then you have to resect it so but that that's how the acute tears that acute locked knee that you just can't bend or straighten at all essentially that needs those those patients end up in a e don't they sometimes versions and if they're going to have surgery it needs to be done quite quickly to help preserve it yeah i mean i've had some people that have struggled with uh bucket handle tears for a year amazing yeah yeah um because nhs waiting lists are dreadful but i mean i ideally the sooner you repair them the better the results yeah yeah absolutely okay so and you we talked at the beginning that there's two meniscus or menisci yeah um the medial and the lateral so what we've just talked about there with and obviously that's medial is pain on the inside and lateral is pain on the outside does it change if it's media or lateral in the case of an acute meniscal tear no no no they all need repairing acutely if you can yeah okay so how are you going to get that diagnosis that you've got acute municipal tear they've come into your clinic and obviously you're very suspicious from your clinical examination what's the next stage diagnostically to gain that information that you need about the zones and what you're going to do mri yeah mri scan so we're very lucky here we have uh in immediate access to mri scans so we in my clinic every day we have five or six mri slots yeah so patients can come in they get history taken by me they get examined by me or one of my colleagues they go straight into the mri scanner straight back we see them afterwards yeah look at the images on the screen together uh often with the radiologists and decide what pattern of tear it is and in what area of the meniscus it is and how we're going to manage them right yeah perfect that's what's great here is you've got that ability just to that one stop clinic really isn't it to get the information and if we are saying it is you know it is partly time dependent there's no doubt about it it's important to get that information as soon as possible so from the mri we've talked a little bit about the zones so my uh my understanding is that it's to do with blood supply partly to the meniscus can you talk us through that certainly it used to be i don't know if i'm fully up to date no you're completely up to date i'm sure so uh when you look at this meniscus in cross section it looks like a a longitudinal triangle out towards the edge it's thick and fat and it's got a big fat blood supply and on the inside it becomes very thin and it's got a very poor blood supply so the ones that are repairable are the ones out towards the rim of the meniscus with the better blood supply yeah you do do zone red zone was it blue and red it's red pink and and and white sorry man as you go as you go from the outside to the inside yeah so the more peripheral you are with the meniscus the more repairable they are right yeah and obviously if it's a bucket handle then that's going to need an operation correct something that's flipped over okay and so so the the corollary of that yeah is that the smaller tears on the inner third of the meniscus where the meniscus is very thin and fragile yeah they're not repairable right they're less severe then we're not so worried about them they will often settle down on their own uh the ones that don't you you can resect at a later date if necessary right okay and the mri is going to give you that information the mri gives you a lot of information uh but the final arbiter bizarrely as to whether or not a meniscus is going to be repairable or is actually the arthroscopy so once you've actually so gone once you've decided that someone doesn't need it or may need a repair yeah you have to arthroscope them put a camera in the knee look at the meniscus probe the meniscus carefully work out is this tissue strong enough to be repaired yeah and then repair it so so you're literally poking the meniscus yeah we could make it sound more technical but we won't poke the meniscus and if it moves and it's not stable then does the meniscus relocate back into the position it needs to be right does the tissue feel strong enough to be stitched yeah and then at the end of surgery at the end of surgery does it does the repair look strong enough to be sustainable yeah and that depends on people like me who do this all day long so you certainly need to see somebody that's got that experience it's quite sounds quite subjective when you say it like that yeah yeah and i remember when i had mine done the surgeon said well i'm going to go he said exactly that i'm going to go in if i can repair it he actually said if i can repair it i will are you happy with that because the post-operative side of things is quite different and we'll come on to that um but he said in the end i'm too old and it looked it didn't didn't look repairable so he just cut it out and that's fine but obviously if you're younger then you but but i appreciate that as i get older that probably means i'm going to have some medial compartment so inside osteoarthritis so let's say you've gone in and you've decided that you want to repair it what do you actually do to the meniscus so you cancel the patient very carefully as to whether you say that you're going to try and repair the meniscus and you talk the patient clearly through what the two processes involve and what you do is you use a range of stitching techniques to hold the bits of the meniscus back in place right so it's often sometimes it can be simply like stitching a cut in the skin back together again sometimes though you're trying to reassemble bits of a jigsaw puzzle yeah with the more complicated tears and you have to do different types of stitching for different shapes shaped tears yeah yeah and so we have three real techniques one is called the inside out technique whereas a a device passes stitches in and the stitches get pulled out the other side to hold the meniscus in place the other is a reverse when the stitches get passed through the meniscus from the outside and that's called outside in yeah and then the last one is an oil inside where you're putting a camera or a gun inside the meniscus which is firing firing stitches inside to stitch sort of grabbing it and putting it yes do you ever stitch to the bone like into to anchor that's great yes so for the for the real difficult tears back at the roots at the rear of the meniscus then we have to use bony tunnels and anchor anchor the meniscus back down onto the bone that's a bit more complicated more complicated okay so let's say you've gone in and i'm sure there'll be people listening that are have been told exactly what you've said let's say that they do end up having a repair how does that look post operatively for that patient so this is the other thing you need to uh spell out to patients if they're having a simple meniscectomy in other words removing the torn fragment it's a very simple quick day case procedure they walk in and they limp out yeah and they saw for two or three days for a few days and then they get on with it yeah if they're having a meniscal repair the bad news is although the outcome is going to be great typically the downside is for four weeks you're limping around on crutches in a knee brace yeah which is burdensome boring yeah you see those patients you're on crutches you're in a knee brace how much weight you're allowed to put through the knee and how much range you're allowed in the knee depends upon the type of tear and the quality of the repair right so that will vary yes and that varies almost almost patient to patient but you know i always tell patients the worst case scenario which is your non-weight bearing for four weeks and you're in a knee brace locked at naught to thirty degrees that's naught to about thirteen bend yeah yeah so if they're forewarned that's the worst scenario then anything better than that is is good news short-term short-term pain long-term long-term gain yeah so we see we see the patients that you've operated on and um i mean because they because you've taught them through it carefully they're very aware of it but you know they do get frustrated and it takes time and from a physio point of view we're quite limited we still can do things with them um but whereas as you say with a meniscectomy or resection you don't get that as you say i mean i had one done you know after three or four days it's fine but long-term wise obviously it can compromise the the integrity of the joint um so with those let's just go through that in a bit more detail just as a as you said it varies from patient to patient but let's say you come out you've got your you've had you've had a repair so you've got to look after those sutures because the worst thing you can do is do too much on it and you essentially you've you've ruined the whole show haven't you yes so if you if you're disobedient or uncompliant and you start walking around particularly without a brace or go beyond the range you're supposed to or take it off for whatever reason you can completely disrupt all the good that we've done so you're you're you're you're ruining everything that we yeah so four to six weeks you're probably not putting full weight through the leg you're probably limited from naught to thirty maybe increasing to naught to 16 and then and then what around two to three months you're probably walking without crutches so at four weeks you come and uh see your surgeon who's done your repair uh he or she will typically unlock your brace and then quite rapidly you'll go from two crutches and the brace to no crutches and no brace and that process is supervised by the physiotherapist absolutely and that that normally happens pretty fast so within three or four days yeah of us checking you out at four weeks yeah uh we may even do a a four week scan just to check that everything's in place um and then it's over to you for rehab and then quite quickly patients are back doing non-impact exercise so on a static bike doing some swimming maybe using some cross trainers a low resistance rower just anything to get the knee moving in the range but that would be what sort of mark would they be doing that three months no they'd be doing that sooner so four and a half five weeks post surgery certainly on the we get them on the bike quite quickly um and that's what i found is that i think people feel quite positive that they're actually not just losing you know it's more of a i don't know more of a natural operation isn't it because you're actually well what's the term you're keeping the the anatomy it's yeah you know so i think they feel very positive about that and that initial four to six weeks i think once they're over that it's quite straightforward normally from there isn't it um and then hopefully long term they're in a much better position now the big question we get and i do know the answer but i'd be interested well i think i know the answer is how do you know if it's repaired patients are always asking they get a bit of pain and they're like well have i done something wrong or so when do you re-scan and when do you know that what you've done has repaired that's a great question it's a really good question and you there's a number of ways that you can assess how well a meniscus has repaired or not and that's down to patients symptoms how good does it feel uh what activity they can get back to yeah uh you examine them so if they've got no no swelling in the knee no tenderness no pain when you fully extend them yeah no pain when you twist the knees it's called a murrow's test that's all negative that all bodes very well i think i mentioned muscle muscle mass restoring yeah all the all these body very well we not uncommonly rescan around three months often that's just for reassurance for me and for the patients on the scans to some degree you can assess how well the meniscus has repaired and what's important is when you look at the meniscus you don't want to be able to see uh sort of a water signal where the meniscus tear was yeah it may not heal completely solidly with perfect meniscal tissue but as long as it heals with some form of scar tissue that's enough for it to have kept the shock absorbing capacity of the meniscus and to protect the knee going forwards yeah yeah the gold standard would be to re-arthroscopically go back in uh but of course no one does that no that would be a bit mental yeah although there is something around called the nano scope right uh which the americans are using probably over aggressively which it's an it's a needle-sized camera about one millimeter in diameter that you can put into the knee in the outpatient wow or in the office setting to have a little look inside the knee but we don't do that here but that as a surgeon actually if you did that you'd that would give you more comfort that would give you yeah so some some some guys are doing this to have a look but it's a bit experimental at the moment and it is it's theoretically one of the indications for this new nanoscape but if everything's going in the right direction you're not going to do that right you're just going to listen to the patient they feel great yeah and they'll start going start building back and as you said long term that should help to preserve the joint and that's the same if it's the media or the lateral correct yes yeah um and if you just i think we talked about it earlier but i'm just thinking that if if i was a patient sitting there i've just tore my meniscus and i've got a locked joint will you get a better repair the sooner you go in and do that operation yes right because if it's been locked and if what happens is with time is the the the fibers and the meniscus shorten right so the longer it's locked out the shorter the fibers become the harder it is it is to put the meniscus back in place right okay so we are getting the tongue and the more tension there is on the repair yeah and you want it not to be and the most this may be a silly question but 15 years ago not every orthopedic surgeon was doing repairs true i mean there's a point where it was relatively new uh you know in an nhs hospital now and most surgeons going to be sort of making this decision on a daily basis i would think so yeah i would think so i mean it's certainly it's part of every orthopedic surgeon's argumentarium to do a meniscal repair yeah sure okay anything else you want to say about those acute meniscal repairs no i think it's the best option isn't it if you can if you know if you're young and fit and active and you've got a a significantly sized meniscal tear and it's repairable then i'd advise you to get it repaired yeah okay cool now now there's going to be the other group that we'll talk about well actually before we talk about the other group so let's say you can't repair it can you just talk us through what you do in that that situation the resection of medicine so in those tears that aren't repairable you sadly have to remove those elements of the meniscus which are loose or unstable within the knee and you only resect as little of the meniscus as possible so you want to keep as much of the rim of the meniscus intact to stabilize the knee so you when you reset the meniscus you don't aggressively go in and remove the whole meniscus which they did used yeah years ago that we used to do that back in the 80s take that out yeah don't do that down there yes um but now we're terribly careful preserving as much of the meniscus as possible and we talk about carefully sculpting the meniscus to a nice smooth rim preserving most of its integrity yeah okay and that's the one where if you do that post-operatively pretty straightforward yeah yeah yeah okay let's go on to the what is a massive group of patients that we see so we're probably going getting a bit older now yeah probably late 30s early 40s 50s and upwards exactly so this is more that wear and tear meniscal tear yes you want to just talk to us just remind everybody a little bit about what that group of patients yeah so these are patients here somebody who's in their 50s and 60s walking the dog or someone playing with a doubles tennis i don't know just going shopping and they just they get much similar but less much less severe uh changes and they again they have localized pain some swelling doesn't feel comfortable going downstairs they feel a bit vulnerable you you take the history you get the story of how it how it came on it's normally come on more gradually there's a longer history weeks and months rather than days and weeks yeah yeah um it's sort of been building up it's a bit more insidious it's built up over time yeah you examine them there's obvious muscle wages typically there's a joint diffusion there's very focal joint line tenderness and you think this is a degenerate meniscal tear again they go up for an mri scan and the scan comes back and confirms your suspicions yeah that that it's a meniscal tear so how does that look different on a scan compared to those acute so here the the meniscus looks generally older and generally degenerate and generally more frayed hence the old pair of jeans analogy that's a bit worn and frayed and torn you often see a fatty signal within the meniscus so the meniscus looks old yeah uh on the scan yeah and it's called you know it gets reported as a degenerate complex meniscal tear within that there might be stable or unstable elements so the important issue here is is this municipal tear stable right in other words is just frayed and worn and torn or is it very unstable with loose bits breathing around bits breaking around in either event for a degenerate meniscus you invariably give non-operative management i.e time a bit of rest exercise physiotherapy a run for his money for a good few months yeah and the great news is that about 70 or even more will settle with non-operative management like this often way more in fact in my experience yeah and so you tell the patients this is what they've got you show them the scan and then tell them the good news that the chances are that in three or four months time after some activity modification yeah and physiotherapy maybe your injection of a lubricant or a steroid to help calm the knee down yeah they'll they'll be fine and back to where they were you know before all this started and the bit i suppose for those people that have been sort of diagnosed nosed with those problems it's very hard isn't it to predict although a majority still get better with time and i think you have to be patient with these things it's hard to predict who's going to be the ones that do or don't get better or is there things that you yeah so you do get a funny sense you've been doing this for decades you think yeah but i mean you do you have to roll the dice and give everyone a chance and expect them to get better and yeah three or four months minimum yeah yeah absolutely the only people type of patient i'm thinking where the i'm putting words in your mouth so where an operation maybe is where they keep getting those acute flare-ups and that sort of gives you the impression that something's moving around locking a bit yeah so if if you're you know who would it be it would be someone who's in their 50s or 60s and remains active and they're just struggling and that's not getting better and they say it keeps on giving way on me it keeps on catching keeps on locking up doc yeah yeah and i sort of had to unlock it and clearly they've got a loose piece that's just not scarring up yeah because that's what's what these fray bits of meniscus do they sort of scar scar up and sort of become stable yeah and that's what you want them to do so you even even in that subgroup i think you have to still say well mr smith this you've got to give this a bit of time yes we don't want to have to operate unless we have to yeah so give it three months yeah i mean we've got quite a few patients that you've referred to us with exactly that at the moment i've just come from the clinic so they're in the gym and generally they're all getting better that they're it takes time but it's exactly that whether it's the exercise i think the exercises help but at the same time you are you're waiting for this thing to scar up so as long as you don't just keep irritating it and keep it quiet yeah so it's activity modification so they've got to cut back on their walking again you want to do non-impact non-twisting exercise ask them be careful going up and down stairs careful on the escalators careful on the pavements careful on the cobblestones just look after their knee and you know do their homework and do their exercises with you and then fingers crossed they'll be dancing and a majority do don't they just giving it giving it giving it time are there situation there are still situations i believe where you potentially would operate on these but those are the ones where you've given it time and it's just not getting anywhere yes like i said i have this sort of three-month rule yeah it's way over 70 percent if these will settle yeah yeah absolutely okay and then that sort of leads us into where i want to go to talk about with this older age group which and how this links into municipal terrors which is arthritis or osteoarthritis so and that we talk a lot about certainly from working with patients where they do have arthritis and a meniscal tear yes how does that influence your decision-making does it influence it and what sort of other management strategies might come into place at that point whoa it's a lot of questions yeah so the first question is if you've got a patient with a degenerative meniscal tear with no arthritis compared to a degenerative meniscal tear with arthritis um well you'll still go down the same path for both of them it's just the prognosis in my experience for patients with degenerative meniscal tears with arthritis if you dive in an arthroscope that sub group yeah they're more likely to be unhappy than happy yeah i've definitely seen that not not of any of your patients but there's i've definitely seen less now but certainly five ten years ago where people were having operations keyhole surgery basically gone unarthritis yeah and sometimes it would help but you'd often see they end up with this really swollen synovitic type presentation yes so the mistake that can be made is someone presents with an arthritic knee and as a bit of a side show they've actually got a degenerate meniscal tear the doctor thinks the degenerative medical tear is the main source of the problem removes that so the knee is lost more of its shock absorption and the arthritis then accelerates so it really is a bad idea isn't it yeah yeah yeah um so [Music] degenerate meniscal tears in a degenerate knee gain very much conservative options are supported yeah yeah i mean they generally do um pretty well with physio pain management activity modification and we really work on and even in older patients we get them in the gym we get them you know doing leg press leg extension and building up the quadriceps particularly and we've got lots of techniques to try and build that up and generally speaking people do really well losing a bit of weight can definitely help with knee pain changing your lifestyle a little bit yeah all of these things that that can be very helpful so let's go on now to osteoarthritis yes so massive you know group of patients that we see 40 to 70 50 to 70 year old males and females probably more male than female yeah probably um with osteoarthritis of the knee probably associated with the meniscal text as we've discussed they often go together we're not going to focus on knee replacements at this stage because i think everybody knows if they've got arthritis an arthritic knee there is always the option of a knee replacement at some point but many people want to avoid it they are limited after a knee replacement to a certain extent it's great for reducing pain but they can be limited functionally so for that active person imagine some what are your knees like touch wood pretty good pretty good which is good for an orthopedic surgeon never had your meniscus taken out i had i had a meniscectomy guard 21 years ago wow touch wood it's okay i can still ski on it which is right that's not bad do you know whether it actually has any wear and tear on it it does actually so i had some i had a scan done a couple years ago so that it was a big lateral meniscal tear and with a big cyst and it had most of it removed um but it it lets me know occasionally but i i can do efforting apart from run on it okay do you enjoy running no we see a lot of clients that are like that all they want to do is run on it but that's definitely uh something to think about carefully okay so let's say your knee started to get sore i hope it doesn't simon you're obviously not going to have a knee replacement you want to keep skiing so actually you're you are that classic group that want to stay you know we have a aging population but we have a very active aging population what are your options obviously i'm going to start with physiotherapy which is obviously where we should start with this and i think that will have a role but what would you advise to patients so physiotherapy obviously weight reduction you've mentioned before that's super important really important because the knees are just levers as we get up out of our chairs for example we're putting nine or ten times our body weight through the knee so if your ten key lays over that's a hundred kilos of force going through your force it's all through your knee which doesn't need to but going on to the other other treatments that you're alluding to injectables yes so injectables are very effective in my experience and i think your experience too so absolutely uh we recommend injections but there's a lot of options isn't there out there and there's becoming more and more options and i think it'll be really good to get your opinion around what are the options i suppose but what's your because i know you do lots of quite you know novel um injections as well yes so the more conventional injections would be the ones been around for years so injecting steroids into a knee are these done typically under outside control by one of our radiologists or by your good self in clinic and the steroids will dampen down the pain for a few weeks or a few months and help break that cycle of pain help patients get back to doing more strength training and that can be very effective yeah then there's the lubricant something called hyaluronic acid and that comes in various shapes and forms various viscosities various strengths various shelf lives associated with it i use something called syn risk one which is supposed to be the more long acting of the variants and that can produce symptomatic relief for up to six months and these injections can be repeated uh the insurers there will often pay for a limited number of these yeah um and then europe-wide and across north america there's a huge uh take-up of something called prp these are the blood injections that patients will hear about or read about this where you have some blood taken out of your arm get centrifuged down and inject it into your knee and this is called a platelet-rich plasma and there are loads of studies out there that suggest that's just as good if not more effective than the lubricant injections particularly in knees which is what we're talking about absolutely so osteoarthritis of knees it can be very effective the problem at the moment is the insurers aren't funding it they don't believe that the uh the data is strong enough to support them funding it so a lot of patients have to dip into their own pocket and pay for it themselves uh and then you can go [Music] off track a bit if you want to and explore other cellular options so other cellular options include what i call inverted stem cells where you can you can extract a type of stem cell from your bone marrow and have that injected into your knee yeah but you're starting to get very experimental when you're talking about this yeah and also very expensive yeah so i've certainly had a few clients that you've done what bmac yeah so this bone marrow and they've actually it's they've done very well with it so can you give us a bit more because i'm sure although not everybody's going to go for it i think it's good for people to be aware of what's out there and i think you've alluded to it already it does become experimental and obviously patients just need to weigh up cost versus risk versus benefit but just give us an idea because i'm interested in the process of bmac and and how that works and more importantly what clients do you think do well with it so bone marros concentration injection as i said is experimental and you have to be completely clear that this is the case it involves patient having a light anaesthetic they have a needle put into their hip the bone marrow gets aspirated from the hip bone centrifuged down and injected into their knee at the same sitting um again it's used much more in north america and other centers in europe than it is in the uk we've probably done in total only about 40 patients yeah uh it's been invariably done for osteoarthritic knees occasionally patients will come in and request other joints be injected but it's it's just it represents a tiny percentage of the patients we treat and do you think those patients are coming to you they've read a bit about it or is it you know how do you think they're ending up having it done i suppose um so it's some patients would have just sourced us in indirectly and and come and ask me you know do you do this and how much will it cost and how effective is it and what happens is you say well it's experimental you must go down the standard route of treatment first so you must try everything else first and then then you would go on and talk about all the pros and cons of it and just anecdotally from those 40 patients what's your feeling on how effective it's been probably about two-thirds to three-quarters to see a good result yeah yeah it's it's it's reasonable but it's expensive and it's experimental yeah yeah and i think as long as you make that clear to patients then it's um it's it's it you know it's something that they can then if they can choose how to spend their money to a certain extent yeah but also i think it's very important that they try everything else first yeah sure you know you can have a billionaire walk in here and he says he wants he wants bmac and you say well no you're trying everything else first yeah my i've been as you know i've been doing ultrasound guide injections probably for about 15 years and we do we use steroid which i really like for that acutely swollen synovitic knee just to as you said break that cycle and give that patient the opportunity to exercise a bit strengthen the knee maybe lose a bit of weight and use that three or four months hopefully to to get that the hyaluronic acids i've used again for a very long time austin or duralane um and i think for a mild to moderate arthritic knee or or somebody that also has a bit of a degenerative meniscus that isn't overweight that's pretty active i think that's a really nice um a solution for some of them but it is something that needs to be repeated obviously the great thing about hyaluronic acid is it's not a drug so side effect profile is extremely low and sometimes you can obviously combine the steroid and the hyaluronic acid yeah we often do yeah which i think is a nice combination then prp i got into about five years ago partly because of the trials that came out they are the randomized controlled trials around the knee but also i was definitely getting a group of patients that had that mild to moderate arthritis that were very active lots of tennis players around here that wanted to try something they maybe tried hyaluronic acid but it hadn't worked and a lot of people do want to avoid steroid but certainly long term i don't think you win with steroid i think you're you know you often it you know you have that diminishing effect of how much it helps and i think with prp i would say 50 percent get a good result that they're really happy with and the other how many injections do you give off of your patients yeah it's a good question so i did one this morning and i'm just doing one on them and we're going to see how they go i've done people that i've done two on and then i've had people that we've done three on most of the studies particularly as you say come from north america do three injections but you have to weigh that up with cost and that sort of thing but i think certainly doing three injections doesn't do any harm there's probably a ceiling effect where you might as well not do any more so i think if i would go for three if if if people wanted to go for the full thing but i don't think most most the studies would generally say three but anecdotally i've had good results with one with two i've had patients that have done one they've come back two months later and had a second so i don't think it you have to have three but i don't think it's certainly not going to do you any harm um it just costs more money the other thing we've not talked about is knee off load of braces well we should talk about it yeah so they've become more and more popular so just for patients uh when you have osteoarthritis of your knee you need to understand that the knee joint has three three separate compartments you have one joint where the kneecap articulates with the femoric or the patellofemoral joint then you have an inside joint and an outside joint called the medial and lateral tibiofemoral joints and if you have arthritis on the inside joint which is the most common less so on the outside joint you can have very localized wear so each knee is three joints and we talk about unicompartmental or tricompartmental osteoarthritis now if you've got arthritis just affecting one compartment all your pain is coming from one third of the knee and if you can have a knee brace that will take the stress away from that warm bit of the knee that's very very effective combined with weight loss physiotherapy and injectables you can often get someone uh or stop stop someone needing a joint replacement for many many many years yeah yeah and certainly we've st and obviously the brace that we generally favor is the ossa offloader yeah brace i'm sure there's some others too but um and it's quite lightweight patients can wear it quite a lot because people often go well i can't bother to wear that brace but actually it is quite lightweight yeah once they've got used to using it yeah they like it it's like putting their socks on in the morning they put their brace on um and there are trials aren't there there are some some a few good scientific trials that show that you can really delay the requirement for a knee replacement and we've certainly had success with it and i think one of the key messages that i try and get across to patients like you do too is often there's not one answer to this and actually that multi-modal type approach so weight loss physiotherapy exercise based treatment maybe a brace maybe an injection yeah that sort of combination i think is probably the best option we have and there's never going to be that holy grail for arthritis i don't think and i think having that combination of treatment i'd say a significant percentage of patients do well but then there is definitely a group where basically the knees had it yes and it doesn't matter what wonderful injection you've got or what wonderful exercise you've got for somebody essentially they're going to need a knee replacement sadly yes yeah yeah and we definitely don't have the answer i don't think for for osteoarthritis at this present moment because but the other thing to mention as well we haven't talked about it but on an x-ray or an mri you can have a terrible looking knee can't you that actually causes no pain at all and then we see the other side where somebody walks in in agony limping can hardly move their knee and you do a scan and it's like actually why is that i really wish i knew the answer yeah there's no there's no no there isn't an answer to that some of these scans they have this sort of acute bone marrow edema yeah what that means in english is that the bone underneath the arthritis has suddenly got very very inflamed and i think probably what's happened is a small crack has developed in the cartilage fluid has leaked through that crack into the bone marrow and that's why they suddenly become so painful right and that sets off like an inflammatory inflammatory process in the knee and then you need to have really really rest the knee and offload it yeah yeah again that's one of the uses for the offloaded brace as well yeah you get an acute flare-up of a more chronic arthritis yeah normally on the medial side again typically yeah yeah typically but the great thing about this off-loader brace is they if they're fitted properly go the other side you can use one for the other side and yeah yeah yeah i mean a lot of patients are loving loving those and and avoiding or putting knee replacement surgery off for many many years yeah yeah perfect okay well i think that we've covered we've covered an awful lot and hopefully people find that helpful i think the key messages are is if you're quite young and you've had a meniscal tear is that ideally if ideally obviously you don't have an operation if you don't need one but if you do need one hopefully they can there can be a repair but bear in mind that the rehab can be quite slow because you've got to respect times of healing you can't certainly speed that up and then obviously if you've got something more of a degenerative meniscus which lots of people will have that you need to give that time correct and you're certainly not going to be rushing to a surgeon necessarily um and then when it comes to arthritis i think yeah we've summed up really that you need to throw a few different things at it a few different treatment options because it's unlikely that we've got that one options that's just going to cure everything and that we need to have that sort of combination of treatments um to improve things so simon thank you very much for your time thoroughly enjoyed it a lot me too thank you and um yeah thanks very much all right thanks you

Channel: Complete Physio

Views: 52,681

Keywords: Complete Physio, Physiotherapy, How to stretch, meniscal tear, physio, physiotherapy podcast, meniscus tear, meniscal tear medial, meniscal tears symptoms, meniscal tears nhs, meniscal tear symptoms, meniscus tear nhs, meniscal tears knee, meniscus tear lateral, meniscus surgery, meniscal tear of the knee, knee meniscal tears, meniscus tear knee, meniscal tear treatment, meniscus tear in knee

Id: ybdmdMyHsmA

Length: 48min 21sec (2901 seconds)

Published: Mon Aug 22 2022